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SAN JC.. _JUIN COUNTY ENVIRONMENTAL HEALTH L. ARTMENT SITE MITIGATION MASTER FILE RECORD INFORMATION FORM "MFR"-GREEN FORM DATE 08 ,O Z ZQ SHADED AREAS FOR EHD USE OWNER FIL :COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNEcK1F0wNERIsCuRREwLvoNFnewiTH EHD PROPERTY PHONE OWNER NAME I-IRST M1 I LAST 1-6q --5 3 - & S 3 BUSINESS NAME 1 Qr �+ � E-MAILADDRES r �J ov Ar M/.C43 OWNER HOME ADDRESS ^^ C ql7" ATTENTION:ORCAREOF(OPTIONAL) CITY - T `� STATE ZIP SZ CZ OWNER MAILING ADDRESS I ' I r , J r MAILING ADDRESS CITY STATE , ZIP 11 1. 1 ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER ENVIRONMENTAL ❑ EHD LOCAL VOLUNTARY ❑ RWQCB LEAD— ❑ RWQCB LEAD— ❑ DTSC LEAD ❑FED EPA LEAD ASSESSMENT CLEANUP CORRECTIVE ACTION WATER QUALITY(WDR) 2959 2954 2950 2953 2960/3526/3527 2965 FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No BUSINESSIFACILITYISITE/PROJECT NAMEAPN l - oZO - SITE ADDRESS/PROJECT LOCATION I S a l S. 4,rp Qr T WA-1 BUSINESS PHONE s s3 CIN S C^ STATZIP C Z. (� 1 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS MAILING ADDRESS CITY STATE ZIP SIC CODE COMMENT: REQUESTOR'S INFORMATION: BUSINESS NAME ATTENTIONTr^ MAILING ADDRESS -i ,S PHONE �., CITY O 1 N �4„ STATE ^ ZIP t e EMAIL HCl!•��7 A9VQ f)�A� ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ G REQUESTOR BILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applicant,certify that I am the Olvner, Operator,Authorized Agent, or Responsible Party and I acknowledge that all PERMIT FEES,PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all information provided on this application is true and correct; and that all regulated activities will be performed in accordance With all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party for the project located above under facility/site address, I hereby authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prov ed to me(p%my�representative. APPLICANT NAME(PLEASE PRINT) I C , /- SIGNATURE V V_ ' 1 _ • A/'�.._._ TITLE �� w/� �NA TAX ID# FA#: Gj 71 OWNER ID#: %� II..I ACCOUNT#: - �T ASSIGNEDTO: PR#: �/�„— -5� (�(� ACCOUNTING COMPLETED BY: -[ / (J DATE: /�( SR TYPE PE SC FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE REOUESTib ( U INVOICE# 2903 523 $456.00 �y n Work Plan 2904 523 $760.00 L- X O '*1 t d�0-`l. Site Mitigation MFR 2-26-2018